Tips for Navigating Marketplace Health Insurance Plans

Open enrollment begins in November for coverage starting in 2015.

Healthcare Marketplace

Disorders of consciousness

Acquired brain injury therapy manager Kathy Farris speaks with a caregiver of a person with a disorder of consciousness. Photo by Gary Meek

The Affordable Care Act – otherwise known as “Obamacare” – has ushered in many changes to health insurance coverage. For one thing, many Americans can now buy subsidized health insurance plans through state or federally run exchanges. But not all plans are the same.

Open enrollment for these plans begins soon. Experts at Shepherd Center are offering timely tips to help navigate the process if you are planning to buy or change plans.

The Basics

Good health coverage is important to stay healthy and get the best treatment. Health insurance exchanges are designed for two main groups of people – those who either don’t have insurance or currently purchase their own insurance (not through an employer).

Plans vary by state and there are also different categories or metallic levels ranging from bronze to platinum – each of which will pay less or more of your costs when you need care. These plans have different monthly premiums, deductibles, coinsurance amounts and out-of-pocket expenses. Your income, age, the state in which you live and the size of your family will factor into how much you will pay.

Plan Type

What the Plan Pays

Platinum

90%

Gold

80%

Silver

70%

Bronze

60%

Catastrophic care plans are also available for certain enrollees and can protect against very high medical costs; they act as a safety net in the event of an accident or serious illness. This plan is typically available to people under 30 or those under a certain income level.

In addition to expanding healthcare coverage for the uninsured, the Affordable Care Act also addresses many of the problems with health insurance coverage, including exclusions for pre-existing conditions, lifetime and annual limits, right to cancel insurance policies (right of rescission), and poor benefits and coverage in individual health plans.

“The government also came up with ‘essential health benefits,’ so all [the qualified health] plans offered on the Healthcare Marketplace would have similar and reasonable benefits for consumers,” explained Mitch Fillhaber, senior vice president of corporate development and managed care. Rehabilitation and habilitation services to gain or regain skills or independence (e.g., speech and language, occupational and physical therapy, aids and devices) are included as one of the 10 Essential Health benefits.

10 Essential Benefits of Healthcare Marketplace Insurance Plans

ambulatory patient services

emergency services

hospitalization

laboratory services

maternity and newborn care

mental health and substance abuse services

prescription drugs

rehabilitative and habilitate services and devices

prevention and wellness services and chronic disease management

pediatric services, including oral and vision care

“People who sign up via a health exchange are ensured some type of rehabilitation benefit,” said Fillhaber, adding this is a big step forward. “It was always hit or miss so this is much better in terms of standardizing benefits.”

Still, the plans offered will have differences in:

Covered services/types of treatment

Which providers or hospitals are covered

What is deemed “medically necessary”

Treatment limits (number of visits, lengths of hospital stay, etc.)

Practical Tips

If you are thinking about buying a plan on the exchange, Fillhaber said you may want to:

Do your own investigating. Visit healthcare.gov to find answers to commonly asked questions, learn about the plans for which you are eligible and to use the subsidy calculator tool.

Find out whether your preferred hospital and healthcare providers are in-network by scanning the plan’s list of providers. You may want to double check with your hospital’s or physician’s business office to confirm they are participating in the plan. Because the trend is toward narrow networks, ask yourself if you are willing to trade choice for price.

Know your benefits and what you can afford. Print out the summary of benefits for the plans you are considering and compare what is covered and estimate out-of-pocket expenses. Individuals and families with incomes between 100 and 400 percent of the federal poverty level are eligible for subsidies for premiums. There are also new ceilings on out-of-pocket expenses to protect individuals from high costs, but these may only apply to in-network benefits.

Make sure the pricing is still competitive for the health services you are already receiving if you are already enrolled.

Call health plan customer service lines to verify online information.

Planning for the Worst Case

So, how much coverage is enough in the event of a traumatic injury? Fillhaber explained the more severe the accident or illness, the more time and services would be required.

“At Shepherd Center, patients with acquired brain and/or spinal cord injuries average between 30 to 60 or more days before moving on to a day or outpatient program either in Atlanta or back in their local community,” he said.

Some plans have exceptions for costly illnesses or injuries that weren’t anticipated or that exceed the capabilities of the current network. For this reason, Fillhaber encourages patients to request Shepherd Center in the event of a catastrophic occurrences.

“It gives us the opportunity to negotiate an exception with that health plan and hopefully care for that patient,” he said. “Some of the networks are narrow, so we are doing our best to reach out to all exchange providers to identify what it would take to participate in their networks.”

Enrolling

Open enrollment begins Nov. 15 and runs through mid-February.

There are four ways to sign up for your state's Health Insurance Marketplace.

Shepherd Center, located in Atlanta, Georgia, is a private, not-for-profit hospital specializing in medical treatment, research and rehabilitation for people with spinal cord injury, brain injury, multiple sclerosis, spine and chronic pain, and other neuromuscular conditions. Founded in 1975, Shepherd Center is ranked by U.S. News & World Report among the top 10 rehabilitation hospitals in the nation. In its more than four decades, Shepherd Center has grown from a six-bed rehabilitation unit to a world-renowned, 152-bed hospital that treats more than 935 inpatients, 541 day program patients and more than 7,300 outpatients each year.